Hedman Counseling - Secure Client Area

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Terms and Policy

DISCLOSURE STATEMENT &amp; POLICIES

REGULATION OF MENTAL HEALTH PROFESSIONALS IN
COLORADO:

1. Hedman Counseling, PC is located at 4297 Austin Bluffs
Parkway, Suite 204; Colorado Springs, CO 80918; 719-235-5325. The
mental health professional located at Hedman Counseling, PC is
Heather Tucker. Heather earned a Bachelor of Arts in Psychology
from Baylor University in 1993 and a Master's degree in Clinical
Psychology from University of Colorado at Colorado Springs in
1998. Heather has been a Licensed Professional Counselor,
LPC.0002663, since October of 2000.

2. Everyone fifteen (15) years and older must sign this
disclosure statement. A parent or legal guardian with the
authority to consent to mental health services for their minor
child/ren, must sign this disclosure statement on behalf of their
minor child under the age of fifteen (15) years old. This
disclosure statement contains the policies and procedures of
Hedman Counseling, PC/Heather Tucker and is HIPAA compliant. No
medical or psychotherapeutic information, or any other
information related to your privacy, will be revealed without
your permission unless mandated by Colorado law and Federal
regulations (42 C.F.R. Part 2 and Title 25, Article 4, Part 14
and Title 25, Article 1, Part 1, CRS and the Health Insurance
Portability and Accountability Act (HIPAA), 45 C.F.R. Parts 142,
160, 162 and 164).

3. The Colorado Department of Regulatory Agencies ("DORA"),
Division of Professions and Occupations ("DOPO") has the general
responsibility of regulating the practice of Licensed
Psychologists, Licensed Social Workers, Licensed Professional
Counselors, Licensed Marriage and Family Therapists, Certified
and Licensed Addiction Counselors, and registered individuals who
practice psychotherapy. The agency within DORA that specifically
has responsibility is the Mental Health Section, 1560 Broadway,
Suite #1350, Denver, CO 80202, (303) 894-2291 or (303) 894-7800;
DORA_MentalHealthBoard@state.co.us. The State Board of
Registered Psychotherapists regulates Registered
Psychotherapists, and can be reached at the address listed above.
Clients are encouraged, but not required, to resolve any
grievances through Hedman Counseling, PC/Heather Tucker's
internal process.

4. You, as a client, may revoke your consent to treatment or the
release or disclosure of confidential information at any time in
writing and given to your therapist.

Certified Addiction Counselor I (CAC I) must be a high school
graduate, complete required training hours and 1,000 hours of
supervised experience. Certified Addiction Counselor II (CAC II)
must complete additional required training hours and 2,000 hours
of supervised experience. Certified Addiction Counselor III (CAC
III) must have a bachelor's degree in behavioral health, complete
additional required training hours and 2,000 hours of supervised
experience. Licensed Addiction Counselor must have a clinical
master's degree and meet the CAC III requirements. Licensed
Social Worker must hold a masters degree in social work.
Psychologist Candidate, a Marriage and Family Therapist
Candidate, and a Licensed Professional Counselor Candidate must
hold the necessary licensing degree and be in the process of
completing the required supervision for licensure. Licensed
Clinical Social Worker, a Licensed Marriage and Family Therapist,
and a Licensed Professional Counselor must hold a masters degree
in their profession and have two years of post-masters
supervision. A Licensed Psychologist must hold a doctorate degree
in psychology and have one year of post-doctoral supervision.
Registered Psychotherapist is a psychotherapist listed in
Colorado's database and is authorized by law to practice
psychotherapy in Colorado but is not licensed by the state and is
not required to satisfy any standardized educational or testing
requirements to obtain a registration from the state. Registered
psychotherapists are required to take the jurisprudence exam.

6. I am a Licensed Professional Counselor, listed in the Colorado
database, and thereby authorized to practice psychotherapy. I
seek ongoing education and consultation with other mental health
professionals.

CLIENT RIGHTS AND IMPORTANT INFORMATION:

As a client you are entitled to receive information from me about
my methods of therapy, the techniques I use, the duration of your
therapy, if I can determine it, and my fee structure.
Please ask if you would like to receive this information.

I also offer a reduced fee structure for those with significant
financial need when sessions are available. If you are unable to
pay the standard hourly fee, please talk to me about alternative
payment options.

Administrative or research services required for adjunct services
outside of Hedman Counseling Center will be charged at $120.00
per hour.

It is the policy of my practice to collect all fees at the time
of service, unless you make arrangements for payment and we both
agree to such an arrangement. In addition, I request that you
fill out a "Credit Card Authorization" form to keep in your file.
All accounts that are not paid within thirty (30) days from the
date of service shall be considered past due. If your account is
past due, please be advised that I may be obligated to turn past
due accounts over to a collection agency or seek collection with
a civil court action. By signing below, you agree that I may seek
payment for your unpaid bill(s) with the assistance of a
collections agency. Should this occur, I will provide the
collection agency or Court with your Name, Address, Phone Number,
and any other directory information, including dates of service
or any other information requested by the collection agency or
Court deemed necessary to collect the past due account. I will
not disclose more information than necessary to collect the past
due account. I will notify you of my intention to turn your
account over to a collection agency or the Court by sending such
notice to your last known address.

Therapy fees and treatment are based on a 45-55 minute clinical
hour instead of a 60 minute clock hour so that I may review my
notes and assessments on your behalf.

I am not a Medicaid provider. If you have Medicaid
coverage that includes mental health services, I am not
able to offer mental health services to you.

Legal Services incurred on your behalf are charged at a higher
rate including but not limited to: attorney fees I may incur in
preparing for or complying with the requested legal services,
testimony related matters like case research, report writing,
travel, depositions, actual testimony, cross examination time,
and courtroom waiting time. The higher fee is $500.00 per hour.

Hedman Counseling is proud to support the non-profit organization
Love146. For every counseling session you purchase with Hedman
Counseling, 2% of the net proceeds are donated to Love146.

Restrictions on Uses:

2. You are entitled to request restrictions on certain uses and
disclosures of protected health information as provided by 45 CFR
164.522(a), however Hedman Counseling, PC/Heather Tucker is not
required to agree to a restriction request. Please review Hedman
Counseling, PC/Heather Tucker's Notice of Privacy Policies for
more information.

Second Opinion and Termination:

3. You are entitled to seek a second opinion from another
therapist or terminate therapy at any time.

Sexual Intimacy:

4. In a professional relationship (such as psychotherapy), sexual
intimacy between a psychotherapist and a client is
never appropriate. If sexual intimacy occurs
it should be reported to DORA at (303) 894-2291, Mental Health
Section, 1560 Broadway, Suite 1350, Denver, Colorado 80202; State
Board of Registered Psychotherapists.

Confidentiality:

5. Generally speaking, the information provided by and to a
client during therapy sessions is legally confidential if the
psychotherapist is a Licensed Psychologist, Licensed Social
Worker, Licensed Professional Counselor, Licensed Marriage and
Family Therapist, Certified and Licensed Addiction Counselor, or
a Registered Psychotherapist. If the information is legally
confidential, the psychotherapist cannot be forced to disclose
the information without the client's consent or in any court of
competent jurisdiction in the State of Colorado without the
consent of the person to whom the testimony sought relates.

6. There are exceptions to this general rule of legal
confidentiality. These exceptions are listed in the Colorado
statutes, C.R.S. 12-43-218. You should be aware that provisions
concerning disclosure of confidential communications does not
apply to any delinquency or criminal proceedings, except as
provided in C.R.S 13-90-107. There are additional exceptions that
I will identify to you as the situations arise during treatment
or in our professional relationship. For example, I am required
to report child abuse or neglect situations; I am required to
report the abuse or exploitation of an at-risk adult or elder or
the imminent risk of abuse or exploitation; if I determine that
you are a danger to yourself or others, including those
identifiable by their association with a specific location or
entity, I am required to disclose such information to the
appropriate authorities or to warn the party, location, or entity
you have threatened; if you become gravely disabled, I am
required to report this to the appropriate authorities. I may
also disclose confidential information in the course of
supervision or consultation in accordance with my policies and
procedures, in the investigation of a complaint or civil suit
filed against me, or if I am ordered by a court of competent
jurisdiction to disclose such information. You should also be
aware that if you should communicate any information involving a
threat to yourself or to others, I may be required to take
immediate action to protect you or others from harm. In addition,
there may be other exceptions to confidentiality as provided by
HIPAA regulations and other Federal and/or Colorado laws and
regulations that may apply.

Additionally, although confidentiality extends to communications
by text, email, telephone, and/or other electronic means, I
cannot guarantee that those communications will be kept
confidential and/or that a third-party may not access our
communications. Even though I may utilize state of the art
encryption methods, firewalls, and back-up systems to help secure
our communication, there is a risk that our electronic or
telephone communications may be compromised, unsecured, and/or
accessed by a third-party. Please review and fill out Hedman
Counseling, PC/Heather Tucker's Consent for Communication of
Protected Health Information by Unsecure Transmissions.

"No Secrets" Policy:

7. When treating a couple or a family, the couple or family is
considered to be the client. At times, it may be necessary to
have a private session with an individual member of that couple
or family. There may also be times when an individual member of
the couple or family chooses to share information in a different
manner that does not include other members of the couple or
family (i.e on a telephone call, via email, or via private
conversation). In general, what is said in these individual
conversations is considered confidential and will not be
disclosed to any third party unless your therapist is required to
do so by law. However, in the event that you disclose information
that is directly related to the treatment of the couple or family
it may be necessary to share that information with the other
members of the couple or the family in order to facilitate the
therapeutic process. Your therapist will use their best
judgment as to whether, when, and to what extent such disclosures
will be made. If appropriate, your therapist will first give the
individual the opportunity to make the disclosure
themselves. This "no secrets" policy is intended to allow
your therapist to continue to treat the couple or family by
preventing, to the extent possible, a conflict of interest to
arise where an individual's interests may not be consistent with
the interests of the couple or the family being treated. If you
feel it necessary to talk about matters that you do not wish to
have disclosed, you should consult with a separate therapist who
can treat you individually.

Extraordinary Events:

8. In the case that I become disabled, die, or am away on an
extended leave of absence (hereinafter "extraordinary event,")
the following Mental Health Professional Designee will have
access to my client files. If I am unable to contact you prior to
the extraordinary event occurring, the Mental Health Professional
Designee will contact you. Please let me know if you are not
comfortable with the below listed Mental Health Professional
Designee and we will discuss possible alternatives at this time.

Tara Hedman, Registered Psychotherapist

4297 Austin Bluffs Pkwy, Suite #204

Colorado Springs, CO 80918

Telephone: 719-235-5325

The purpose of the Mental Health Professional Designee is to
continue your care and treatment with the least amount of
disruption as possible. You are not required to use the Mental
Health Professional Designee for therapy services, but the Mental
Health Professional Designee can offer you referrals and transfer
your client record, if requested.

Electronic Records:

9. Hedman Counseling, PC/Heather Tucker may keep and store client
information electronically on Hedman Counseling, PC/Heather
Tucker's laptop or desktop computers, and/or some mobile devices.
In order to maintain security and protect this information,
Hedman Counseling, PC/Heather Tucker may employ the use of
firewalls, antivirus software, changing passwords regularly, and
encryption methods to protect computers and/or mobile devices
from unauthorized access. Hedman Counseling, PC/Heather Tucker
may also remotely wipe out data on mobile devices if the mobile
device is lost, stolen, or damaged.

Hedman Counseling, PC/Heather Tucker may use electronic backup
systems such as external hard drives, thumb drives, or similar
methods. If such backup methods are used, reasonable
precautions will be taken to ensure the security of this
equipment and they will be locked up for storage. Hedman
Counseling, PC/Heather Tucker uses a cloud-based service for
storing or backing up information. The cloud-based backup
system Hedman Counseling, PC/Heather Tucker uses is Counsol.com
and the email service provider Hedman Counseling, PC/Heather
Tucker uses is Counsol.com. Hedman Counseling, PC/Heather Tucker
may maintain the security of the electronically stored
information through encryption and passwords. In addition, in
order to maintain security of the electronically stored
information Hedman Counseling, PC/Heather Tucker has employed the
following security measures:

Entered into a HIPAA Business Associates Agreement with the
cloud-based Hedman Counseling, PC/Heather Tucker and email
service provider. Because of this Agreement, the cloud-based
Hedman Counseling, PC/Heather Tucker and email service provider
are obligated by federal law to protect the electronically stored
information from unauthorized use or disclosure.

The computers that store the electronically stored information
are kept in secure data centers, where various security measures
are used to maintain the protection of the computers from
physical access by unauthorized persons.

The cloud-based Hedman Counseling, PC/Heather Tucker and email
service provider employ various security measures to maintain the
protection of these backups from unauthorized use or disclosure.

It may be necessary for other individuals to have access to the
electronically stored information, such as the cloud-based Hedman
Counseling, PC/Heather Tucker or email service provider's
workforce members, in order to maintain the system itself.
Federal law protecting the electronically stored information
extends to these workforce members. If you have any questions
about the security measures Hedman Counseling, PC/Hether Tucker
employs, please ask.

10. I acknowledge that communications with my therapist
(e.g. emails, chats, or video sessions) via Hedman Counseling,
PC/Hether Tucker's client portal are encrypted and that emails
sent from or to personal email accounts are not secure. I
acknowledge and agree that all communication of a clinical nature
should be sent through the Hedman Counseling Center client
portal. A reasonable attempt will be made by my therapist to read
and respond to the emails received via that site within business
72 hours. I understand that my therapist will not respond to
personal and clinical concerns via regular email or texting.
Email should not be used in the event of crisis or
emergency. As a rule, personal and clinical communications
(i.e. communication for purposes other than scheduling) should be
reserved for scheduled session times (in-person sessions, video
sessions, email sessions, or phone sessions) except in cases of
emergency. I further acknowledge that if either I or my
therapist uses a cell phone that the conversation may not be
secure and therefore not confidential. Although my therapist has
taken substantial steps to ensure the confidentiality and privacy
of therapy provided online, Hedman Counseling, PC/Heather Tucker
cannot guarantee the security of any internet or cell phone
transmissions or communications. I agree to take full
responsibility for the security of any communication or treatment
documentation on my own computer and in my physical location. If
my therapist believes I am a danger to, or may become a danger
to, yourself or anyone else, my therapist may inform others or
insist that I be evaluated, in person, by another health care
professional.

AS A CLIENT:

You as a Client agree and understand the following:

1. I understand that Hedman Counseling, PC/Heather Tucker may
contact me to provide appointment reminders or information about
treatment alternatives or other health-related benefits and
services that may be of interest to me in accordance with Hedman
Counseling, PC/Heather Tucker's Consent for Communication of
Protected Health Information by Unsecure Transmissions.

2. I understand that if I initiate communication via electronic
means that I have not specifically consented to in Hedman
Counseling, PC/Heather Tucker's Consent for Communication of
Protected Health Information by Unsecure Transmissions, I will
need to amend the consent form so that my therapist may
communicate with me via this method.

3. I understand that there may be times when my therapist may
need to consult with a colleague or another professional, such as
an attorney or supervisor, about issues raised by me in therapy.
My confidentiality is still protected during consultation by my
therapist and the professional consulted. Only the minimum amount
of information necessary to consult will be disclosed. Signing
this disclosure statement gives my therapist permission to
consult as needed to provide professional services to me as a
client. I understand that I will need to sign a separate
Authorization for Release of Information for any discussion or
disclosure of my protected health information to another
professional besides a colleague, supervisor or attorney retained
by my therapist.

4. I understand that, in general, Hedman Counseling, PC/Heather
Tucker does not provide Teletherapy, such as therapy over
telephone or video chat. I understand that communications via
email and text should be limited to administrative purposes and
not used as an avenue for therapy. I understand that should I
want Teletherapy, I will discuss my request with my therapist. I
understand that it is in my therapist's sole discretion whether
to accommodate my request for Teletherapy. Should my
therapist and I determine that Teletherapy is an appropriate
option for my treatment, I understand that I will be required to
sign a separate teletherapy disclosure statement.

If client or therapist is unable to attend in-office appointment
due to inclement weather or other unforeseen circumstances, when
feasible session may take place by phone or secure video chat at
the previously agreed upon time. Payment cancellation policies
remain in effect. Please discuss this option with your
therapist in advance if you wish to utilize this option.

5. I understand that my therapist, does not accept personal
Facebook, LinkedIn, Twitter, Instagram, and/or other
friend/connection/follow requests via any Social Media. Any such
request will be denied in order to maintain professional
boundaries. I understand that Hedman Counseling, PC/Heather
Tucker has, or may have, a business social media account page. I
understand that there is no requirement that I "like" or "follow"
this page. I understand that should I "like" or choose to
"follow" Hedman Counseling, PC/Heather Tucker's business social
media page that others will see my name associated with "liking"
or "following" that page. I understand that this applies to any
comments that I post on Hedman Counseling, PC/Heather Tucker's
page/wall as well. I understand that any comments I post
regarding therapeutic work between my therapist and I will be
deleted as soon as possible. I agree that I will refrain from
discussing, commenting, and/or asking therapeutic questions via
any social media platform. I agree that if I have a therapeutic
comment and/or question that I will contact my therapist through
the mode I consented to and not through social
media.

6. I understand that Hedman Counseling, PC/Heather Tucker uses
testimonials in its marketing efforts. I understand that I will
never be asked to provide a testimonial and I am not required or
expected to provide one. If I wish to provide a testimonial
regarding my experience with Hedman Counseling, PC/Heather
Tucker, I may put the information in writing and provide it to my
therapist, along with my signature and the following
statement: "It is my intent to provide Hedman Counseling,
PC/Heather Tucker with a testimonial to be used in its marketing
efforts. I offer this of my own volition and have not been
solicited to provide this testimonial. I understand that it may
be possible for others to identify me based on the information I
provide." No client names will be disclosed in testimonials.

7. I understand that if I have any questions regarding social
media, review websites, or search engines in connection to my
therapeutic relationship, I will immediately contact my therapist
and address those questions.

8. I understand my therapist provides non-emergency
therapeutic services by scheduled appointment only. If,
for any reason, I am unable to contact my therapist by the
telephone number provided to me, 719-235-5325, and I am having a
true emergency, I will call 911, check myself into
the nearest hospital emergency room, call Pikes Peak Mental
Health Crisis Line at 719-635-7000, Colorado's Crisis Hotline
(844) 493-8255 or the National Suicide Prevention Lifeline at
1-800-273-TALK(8255). Hedman Counseling, PC/Heather Tucker
does not provide after-hours service without an
appointment. If I must seek after-hours treatment from
any counseling agency or center, I understand that I will be
solely responsible for any fees due. I understand that if I
leave a voicemail for my therapist on the phone number provided,
my therapist will return my call by the end of the next business
day, excluding holidays and weekends.

9. If my therapist believes my therapeutic issues are above
their level of competence, or outside of their scope of practice,
my therapist is legally required to refer, terminate, or
consult.

10. I understand that I am legally responsible for payment for
my therapy services. If for any reason, my insurance
Hedman Counseling, PC/Heather Tucker, HMO, third-party payer,
etc. does not compensate my therapist, I understand that I remain
solely responsible for payment. I also understand that signing
this form gives permission to my therapist to communicate with my
insurance Hedman Counseling, PC/Heather Tucker, HMO, third-party
payer, collections agency or anyone connected to my therapy
funding source regarding payment. I understand that my insurance
Hedman Counseling, PC/Heather Tucker may request information from
my therapist about the therapy services I received which may
include but is not limited to: a diagnosis or service code,
description of services or symptoms, treatment plans/summary, and
in some cases my therapist's entire client file. I understand
that once my insurance Hedman Counseling, PC/Heather Tucker
receives the information I or my therapist has no control of the
security measures the insurance Hedman Counseling, PC/Heather
Tucker takes or whether the insurance Hedman Counseling,
PC/Heather Tucker shares the required information. I understand
that I may request from my therapist a copy of any report Hedman
Counseling, PC/Heather Tucker submits to my insurance Hedman
Counseling, PC/Heather Tucker on my behalf. Failure to pay
will be a cause for termination of therapy services.

11. I understand that this form is compliant with HIPAA
regulations and no medical or therapeutic information or other
information related to my privacy, will be released without
permission unless mandated by Colorado law as described in this
form and the Notice of Privacy Policies and Practices. By signing
this form, I agree and acknowledge I have received a copy of the
Notice or declined a copy at this time. I understand that I may
request a copy of the Notice at any time.

12. As a client, you may request a copy of your Client Record at
any time. In accordance with the Rules and Regulations of the
State Board of Registered Psychotherapists, I will maintain your
client record (consisting of disclosure statement, contact
information, reasons for therapy, notes, etc.) for a period of
seven (7) years after the termination of therapy or the date of
our last contact, whichever is later. I cannot guarantee a copy
of your Client Record will exist after this seven-year period.

13. I understand that if I have any questions about my
therapist's methods, techniques, or duration of therapy, fee
structure, or would like additional information, I may ask at any
time during the therapy process. By signing this disclosure
statement I also give permission for the inclusion of my
partners, spouses, significant others, parents, legal guardians,
or other family members in therapy when deemed necessary by
myself or my therapist. I agree that these parties will have to
sign a separate Consent for Third-Party Participation Agreement
or may have to sign a separate disclosure statement in order to
participate in therapy.

14. I understand that should I choose to discontinue therapy for
more than sixty (60) days by not communicating with Hedman
Counseling, PC/Heather Tucker or my therapist, my treatment will
be considered "terminated." I may be able to resume therapy after
the sixty (60) day period by discussing my decision to resume
therapy services with Hedman Counseling, PC/Heather Tucker.
Ability to resume therapy after sixty (60) days will depend upon
my therapist's availability and will be within their sole
discretion. This disclosure statement will remain in effect
should I resume therapy if one (1) year has not elapsed since my
last session. However, I may be asked to provide additional
information to update my client record. I understand
"discontinuing therapy" means that I have not had a session with
my therapist for at least sixty (60) days, unless otherwise
agreed to in writing.

15. There is no guarantee that psychotherapy will yield positive
or intended results. Although every effort will be made to
provide a positive and healing experience, every therapeutic
experience is unique and varies from person to person. Results
achieved in a therapeutic relationship with one person are not a
guarantee of similar results with all clients.

16. I understand that my therapist may refer me to and/or expect
me to avail myself of outside supportive resources, including,
but not limited to, other health care professionals, as deemed
appropriate. A failure on my part to comply with such
recommendations may result in termination of the therapeutic
relationship. I understand that my therapist will discuss this
with me prior to terminating the therapeutic relationship for
this reason. It is acknowledged that online or distance
counseling is not a substitute for medication given under the
care of a psychiatrist or doctor. I understand and agree
that Tara Hedman is neither a psychiatrist nor a doctor and is
therefore not legally allowed to prescribe medications or to give
medical advice. It is further understood that online or distance
counseling is not appropriate if you are experiencing a crisis or
having suicidal or homicidal thoughts.

17. Because of the nature of therapy, I understand that my
therapeutic relationship has to be different from most other
relationships. In order to protect the integrity of the
counseling process the therapeutic relationship must remain
solely that of therapist and client. This means that my therapist
cannot be my friend, cannot have any type of business
relationship with me other than the counseling relationship (i.e.
cannot hire me, lend to or borrow from me; or trade or barter for
services in exchange for counseling); cannot have any kind of
romantic or sexual relationship with a former or current client,
or any other people close to a client, and cannot hold the role
of counselor to their relatives, friends, the relatives of
friends, people known socially, or business contacts.

18. I understand that should I cancel within 24 hours of my
appointment or fail to show up for my scheduled appointment
without notice ("no-show"), excluding emergency situations, my
therapist has a right to charge my credit card on file, or my
account, for the full amount of my session.

19. I also affirm, by signing this form, I am at least fifteen
(15) years old and consent to treatment and therapy services here
at Hedman Counseling, PC/Heather Tucker or that I am the legal
guardian and/or custodial parent with the legal right to consent
to treatment for any minor child/ren who is under the age of
fifteen (15), for whom I am requesting therapy services here at
Hedman Counseling, PC/Heather Tucker.

20. I understand that if I am consenting to treatment and therapy
services for my minor child/ren that my therapist will request
that I produce the Court Order Custody Agreement and/or Parenting
Plan that grants me the authority to consent to mental health
services for my minor child. Further, I understand and agree to
keep my therapist informed of any proceedings or supplemental
court orders that affect my parenting rights, custody
arrangements, and decision-making authority. I understand that
failing to provide the Court Order Custody Agreement and/or
Parenting Plan will prohibit my therapist from providing therapy
to my minor child/ren. I understand that it is beyond the scope
of my therapist's practice to provide custody recommendations.
Any request for custody recommendations will be denied. A Court
is able to appoint professionals with the expertise to make such
recommendations.

21. By signing this form, I affirm that I am fully informed of
the therapy services I am requesting and that Hedman Counseling,
PC/Heather Tucker is providing, and grant my consent to receive
such therapy services.

My signature below affirms that the preceding information has
been provided to me in writing by my primary therapist, or if I
am unable to read or have no written language, an oral
explanation accompanied the written copy. I understand my rights
as a client/patient and should I have any questions, I will ask
my therapist.

Electronic Signature of Client or Legal Guardian( Type Full Name )I have read and I agree to the DISCLOSURE STATEMENT & POLICIES